Osteopathy Journals and Research by Darren Chandler

 

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  1. Endoabdominal fascia

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    The endoabdominal fascia lines the abdominal cavity. It is comprised of:

    • Transversalis fascia: outer layer. Lies between the inner surface of the transverse abdominis muscle and the extraperitoneal tissue. 
    • Extraperitoneal tissue: this is a layer of connective tissue between the transversalis fascia and parietal peritoneum.
    • Parietal peritoneum (or fascia): this layer is a thin serous membrane acting as a balloon which lines the abdomen and into which the organs are pressed into from the outside. 
    • Visceral peritoneum (or layer): this layer lines the organs and is known as the visceral peritoneum in the abdomen, pleura in the thorax (Gallaudet, 1931) and pericardium around the heart.

    Transversalis fascia

    Li (2012) defined the transversalis fascia as lining the inner surface of the transversus abdominis. It can be divided into two layers, superficial and deep, with a dividing intermediate layer between the two:

    • Superficial layer of the transversalsis fascia: closely covers the internal surface of the transversus abdominis and its aponeurosis.
    • Intermediate layer: is an amorphous fibroareolar space filled with fat and loose fibrous tissue. It lies between the superficial and deep layers of the transversalis fascia.
    • Deep layer of the transversalis fascia: a loose amorphous fibroareolar space lies between the deep layer of the transversalis fascia and the peritoneum.

    Superiorly

    Superiorly the superficial and deep layers fuse and blend with the fascia covering the inferior surface of the diaphragm. Forming the subdiaphragmatic fascia the transversalis fascia travels through the medial and lateral arcuate ligaments and aortic hiatus to become the endothoracic fascia. 

    Anteriorly

    Anteriorly the superficial layer covers the inner surface of the transversus abdominis and the posterior rectus sheath (or rectus abdominis). The deep layer lines the outer surface of the peritoneum.

    Posteriorly

    Posteriorly the superficial and deep layers join together and form a continuous sheet anterior to the lumbar fascia.

    From anterior to posterior the transversalis fascia courses over the quadratus lumborum and then the psoas major. At these points the transversalis fascia gets renamed the quadratus lumborum and psoas fascia respectively.

    As the transversalis fascia is the fascia of the quadratus lumborum and psoas whilst extending superiorly to form the subdiaphragmatic fascia it forms the arcuate ligaments.

    The lateral arucate ligament (rib 12 to L1 TP) is a thckening of the quadratus lumborum fascia. The medial arcuate ligament (L1 body to L1 TP) is a thickening of the psoas fascia.

    Laterally

    Laterally Li et al (2012) found the superficial and deep layers to join at the:

    • Outer edge of the quadratus lumborum (at the level of the renal hilum)
    • The outer edge of the psoas major (at the level of L3).
    • Anterior axillary line.

    Also at the outer edge of the quadratus lumborum the transversalis fascia blends with the lateral conal fascia* (Li et al 2012).

    *: Lateral conal fascia is formed by the lateral fusion of the anterior and posterior renal fascia. Travels laterally inrelation to the posterolateral aspect of the colon and fuses with the lateral parietal peritoneum.

    Inferiorly

    Inferiorly the transversalis fascia is continuous with the endopelvic fascia.

    Inferiorly Meyer (1927) found the transversalis fascia, along with the pelvic fascia with which it is continuous, tightly adheres to the pelvic brim. Hayes (1950) found anteriorly at the pelvic brim the transversalis fascia blends with the periosteum of the dorsal surface of the superior pubic ramus and pubic crest.

    Spaces between the superficial and deep layers of transversalis fascia

    The spaces between the superficial and deep layers of the transversalis fascia are:

    • Extraperitoneal space: the space between the superficial and deep layers of the transversalis fascia.
    • Retroperitoneal space: space behind the peritoneum in the abdominal cavity.
    • Retzius space: the space between the symphysis pubis and bladder. The superficial branch of the deep dorsal vein of the penis in Retzius space penetrates the superior layer of the transversalis fascia to drain into the deep dorsal vein of the penis. 
    • Retroinguinal (Bogros) space: is bound by the transversalis fascia anteriorly, the peritoneum posteriorly and the fascia iliacus laterally. 
    • The inferior epigastric vessels: these vessels penetrate the superior layer of the transversalis fascia as it originates from the external iliac vessels. They run in the matrix between the two layers and then penetrates the superficial layer of the transversalis fascia at the level of the linea arcuata and runs into the rectus sheath.

    Peritoneum

    Parietal and visceral peritoneum

    • Parietal peritoneum (or fascia): this layer is a thin serous membrane acting as a balloon which lines the abdomen and into which the organs are pressed into from the outside. 
    • Visceral peritoneum (or layer): this layer lines the organs. It is known as the visceral peritoneum in the abdomen, pleura in the thorax (Gallaudet, 1931) and pericardium around the heart.
    • Between these parietal and visceral layers is a closed sac with a potential space. This space is called the peritoneal cavity in the abdomen, the pleural space in the thorax and pericardial cavity in the chest.

    The parietal and visceral peritoneum are continuous at:

    • Sides and anterior surface of the ascending and descending colon.
    • Falciform ligament.
    • Lateral margin and part of the anterior surface of the left kidney.
    • Toldt's fascia: visceral peritoneum of the mesocolon fuses with the parietal peritoneum of the retroperitoneum.
    • Retroperitoneal segments of the bowel: most of the duodenum, ascending colon, descending colon and rectum.
    • Intraperitoneal bowel loops suspended by the mesentery: Loop one (abdominal oesphagus, stomach and D1). Loop two (duodenojejunal junction, jejuneum, ileum and usually the caecum). Loop three (transverse colon). Loop four: sigmoid colon and occassionally the descending colon).

    In the region of the aorta and inferior vena cava the parietal peritoneum is continuous with the mesentery of the small intestine.

    Where the visceral peritoneum encloses or suspends organs within the peritoneal cavity, the peritoneum and its related connective tissue forms peritoneal ligaments, omenta and mesenteries.

    Peritoneal ligaments

    Peritoneal ligaments are formed by fused double layers of peritoneum.

    Gastrohepatic ligament: lesser omentum. Stomach: lesser curvature --> Liver: fissure for ligamentum venosum

    Hepatoduodenal ligament: free margin of lesser omentum. Liver: porta hepatis --> D1 and D2: flexure between D1 and D2.

    Gastrosplenic ligament: left lateral extension of the greater omentum and lateral boundary of the lesser sac. Stomach: greater curvature --> Spleen. 

    Splenorenal (lienorenal) ligament: left kidney --> spleen. Surrounds the pancreatic tail and extends to the left anterior pararenal space.

    Gastrocolic ligament: greater omentum. Stomach: greater curvature --> transverse colon.

    Transverse mesocolon & sigmoid mesocolon: the mesocolon attaches the colon to the posterior abdominal and pelvic wall. Refer mesenteries.

    Falciform ligament: separates the liver into the right and left lobes. Peritoneum behind the right rectus abdominis and diaphragm --> Liver: courses cranially along the anterior surface of the liver, blending into the hepatic peritoneal covering and then carries on posterosuperiorly to become the anterior portion of the left and right coronary. Contains the ligament teres (round ligament).

    Coronary and triangular ligaments: Liver --> diaphragm: inferior surface. Bare area* of the liver is delineated by the coronary ligament centrally (anteriorly and posteriorly) and the right and left triangular ligaments laterally.

    * Bare area of Liver: the cranial aspect of the liver is a convex area along the diaphragmatic surface. It is devoid of any ligamentous attachments or peritoneum. This bare area of the liver is attached to the diaphragm by flimsy fibroareolar tissue.

    Ligamentum teres (round ligament): a remnant of the obliterated umbilical vein (ductus venosus). Liver: umbilical fissure --> umbilicus.

    Phrenicocolic ligament: left lateral extension of the root of the transverse mesocolon. Diaphragm: opposite left r10 & r11 --> Transverse-descending colon: left (splenic) colic flexure. Passes below the spleen acting as a suspensory ligament of the spleen.

    Duodenocolic ligament: right colon --> duodenum.

    Mesenteries

    The mesenteries are a double fold of peritoneum that attaches the intestines to the posterior abdominal wall. The mesenteries are classified as the mesentery of the small intestine, the mesentery proper, and the mesentery of the large intestine, the (mescolon.

    Mesentery of the small intestine (mesentery) proper

    The mesentery of the small intestine is a large and broad fan-shaped mesentery. It extends from the D/J junction (just to the left of L2) to the I/C junction (by the right SIJ) and then attaches to the posterior abdominal wall. 

    Mesentery of the large intestine (mesocolon)

    • Mesoappendix: appendix --> back of the lower end of the mesentery close to the I/C junction.
    • Transverse mesocolon: transverse colon --> posterior abdominal wall. Connects to the pancreas, duodenum and greater omentum.
    • Sigmoid mesocolon: sigmoid colon --> pelvic wall. Forms an inverted 'V' attachment. The apex of the 'V' is at the level of the division of the left common iliac artery (anterior to the left sacroiliac joint). The base of the right limb descends to median plane to the level of S3. The left limb descends on the medial side of the left psoas major.

    Sometimes the ascending and descending colon is attached to the posterior abdominal wall by the ascending and descending mesocolon. However, it is more common for the peritoneum to only cover the front and sides of the ascending and descending colon.

    References

    Transversalis, endoabdominal, endothoracic fascia: who's who? (2006). Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P.

    A description of the planes of fascia of the human body, with special reference to the fascia of the abdomen, pelvis and perineum (1931). Gallaudet B

    Intertransversalis fascia approach in urologic laparoscopic operations (2012). Li G, Qian YBai HSong ZHong BJia JShi BZhang X.

    THE PELVIC FLOOR—CONSIDERATIONS REGARDING ITS ANATOMY AND MECHANICS (1927). A. W. Meyer

    ABDOMINOPELVIC FASCIAE (1950). MARK A. HAYES

  2. Myofascial relations of the Femoral and Lateral Femoral Cutaneous nerves

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    Femoral and lateral femoral cutaneous nerve symptoms are a common presentation in osteopathic practise.

    These symptoms are not always caused by an entrapment neuropathy. However cases that are and amenable to osteopathic treatment can be greater understood by appreciating the relation of the femoral nerve and lateral femoral cutaneous nerve to the psoas, iliacus, fascia iliaca and inguinal ligament.

    The key clinical points in this article are:

    • The relationship of the psoas major with the femoral and lateral femoral cutaneous nerves.
    • The relationship of the psoas minor with the fascia iliaca.
    • The relationship of the fascia iliaca and iliacus muscle sandwiching the femoral nerve.
    • Entrapment of the lateral femoral cutaneous nerve in the fascia iliaca-internal oblique septum.
    • Entrapment of the lateral femoral cutaneous nerve in the fascia between the tensor fascia lata and sartorius (including the iliolata ligaments).
    • Treatment options for the fascia iliaca in relation to its anatomical connections to the iliacus, psoas major, psoas minor, inguinal ligament and fascia lata.

    This article outlines:

    • Anatomy of the femoral nerve.
    • Anatomy of the lateral femoral cutaneous nerve.
    • Anatomy of the fascia iliaca.
    • Anatomy of the inguinal ligament (& mechanical movement of the inguinal ligament).
    • Anatomy of the lacunar ligament.
    • Function of the inguinal and lacunar ligaments.

    Anatomy of the femoral nerve

    The femoral nerve is the largest branch of the lumbar plexus originating from the dorsal divisions of the ventral rami of L2-4.

    It descends through the posterior third of the psoas major muscle and emerges from its postero-lateral border at the junction of the muscles upper two thirds and lower one third.

    Desouki et al (2016) found the psoas major composed of two sections. The whole of the lumbar plexus, including the femoral and lateral femoral cuatneous nerves, runs between these two sections:

    • Anterior section: comprises of fleshy slips that arise from the anterolateral part of the vertebral bodies of T12-L5 and their corresponding intervertebral discs. This makes the main part of the psoas major.
    • Posterior section: comprises of strips that originate from the front and lower border of the transverse processes of T12-L5. This makes the accessory part of the psoas major.

    After exiting the psoas major the femoral nerve then travels caudally in the gutter between the bulk of the psoas major and the iliacus deep to the fascia iliaca.

    It enters the thigh behind the inguinal ligament in the potential space of the fascia iliaca compartment (lacuna musculorum). The nerve travels in this compartment tightly sandwiched between the floor, (formed by the iliacus and psoas major) and the roof, (formed from the fascia iliacus).

    This compartment is lateral to the femoral artery and vein being separated from the femoral artery by the fascia iliaca (iliopectineal ligament, refer anatomy of the fascia iliaca).

    Motor innervation: quadriceps femoris and sartorius muscles.

    Sensory innervation: anteromedial surface of the thigh. Via the femoral nerves terminal branch, the saphenous nerve, the medial aspect of the lower leg, ankle and foot. 

    Lateral Femoral Cutaneous Nerve

    The lateral femoral cutaneous nerve arises from the dorsal divisions of L2 and L3.

    It emerges from the lateral border of the psoas major and runs on the anterior surface of the iliacus muscle being covered by the fascia iliaca. The relation of all the nerves of the lumbar plexus to the psoas major is described by Desouki et al (2016) in the section above ‘femoral nerve’. 

    Passing behind the inguinal ligament close to its lateral insertion at the ASIS, the lateral femoral cutaneous nerve perforates the fascia iliaca.

    The lateral femoral cutaneous nerve exits the pelvis via a tendinous canal within the internal oblique-iliac fascia septum. This canal may make the lateral femoral cutaneous nerve susceptible to mechanical entrapment near the ASIS.

    The nerve then runs in an adipose compartment between the sartorius and iliolata ligaments inferior to the ASIS.

    Xu et al (2018) found the iliolata ligaments are 2-3 curtain strip-like structures which attached to the ASIS superiorly and are interwoven with the fascia lata inferomedially, and continued laterally as skin ligaments anchoring to the skin.

    Between the sartorius and tensor fasciae latae, the lateral femoral cutaneous nerves runs in a longitudinal ligamental canal bordered by the iliolata ligaments. 

    Putzer et al (2017) noted dense fascial fibers after dissecting the interval between the tensor fascia lata, sartorius, and rectus femoris. They described a strong band of fibers extending from a proximal-lateral to distal-medial direction. 

    Henry (1957) possibly described these same fascial webs that are found in the layers that occupy “the space between the origins of the rectus femoris and tensor fasciae [lata] muscles, uniting the deep aspects of their sheaths”. 

    Xu et al (2018) identified possible sites of entrapment of the lateral femoral cutaneous nerve in the internal oblique-iliac fascia septum and the iliolata ligaments. Could the dense fascia between the tensor fascia lata and sartorius with the iliolata ligaments also be a site of entrapment for the lateral femoral cutaneous nerve?

    Once in the thigh the lateral femoral cutaneous nerve splits into its terminal cutaneous branches, which usually cross over the sartorius muscle and are covered by the fascia lata.

    Innervation: sensory supply to the lateral aspect of the thigh as far distal as the knee.

    Anatomy of the fascia iliaca

    The fascia iliaca covers the iliacus and psoas muscle. Whilst a single structure the fascia of the iliacus and psoas major are decribed separately.

    Iliacus fascia

    The iliacus fascia lines the pelvis (inner lip of the iliac crest and pelvic brim), covering the iliacus muscle and extending down to the anterior thigh. Meyer (1927) found the iliac fascia to merge very intimately with the periosteum around the pelvic brim and the innominate bone where no muscles seperated the fascia from the underlying bone.

    Around the pelvic brim at the iliopubic ramus, the iliacus fascia receives a slip, when present, from the psoas minor. It also blends superiorly at this point with the transversalis fascia.

    Inferiorly the iliacus fascia blends with the transversalis fascia at:

    • Femoral sheath: the iliacus fascia forms the posterior wall of the femoral sheath. The transversalis fascia, scarpa's fascia and fascia lata form the anterior wall (Lytle 1956).
    • Beneath the lateral part of the inguinal ligament: McWhinne (1835) decsribed the fusion of the iliacus and transversalis fascia as forming a fibrous cul-de-sac preventing the viscera prolapsing beneath the lateral part of the inguinal ligament. Teale (1846) found by "destroying" this aponeurotic cul-de-sac the peritoeum could be pushed "very easily" by the finger between the inguinal ligament and iliacus muscle.

    The transversalis fascia is the fascia anterior to the transverse abdominis and quadratus lumborum extending medially to cover the anterior aspect of the psoas major where it gets renamed the psoas fascia. The fascia seperates these muscles from the retroperitoneal abdominal contents. Superiorly it forms the subdiaphragmatic fascia travelling through the medial and lateral arcuate ligaments and aortic hiatus to become the endothoracic fascia. Inferiorly it blends with the iliacus fascia (Elsharkawy et al 2019) and forms the endopelvic fascia, that lines the walls and floor of the pelvis covering the obturator internus, piriformis, levator ani and coccygeus (Raychaudhuri & Cahill 2008).

    Lateral to the femoral vessels the iliac fascia is continuous with the posterior margin of the inguinal ligament.

    Posterior to the inguinal ligament the iliacus fascia relations are: 

    • Iliopectineal ligament (or arch): the iliacus fascia forms the iliopectineal ligament. This ligament extends from the lateral part of the inguinal ligament to the iliopectineal eminence. It can receive attachments from the psoas minor.

    The iliacus fascia then extends from the iliopectineal eminence to the hip joint capsule.

    The iliopectineal ligament acts as a septum dividing the space under the inguinal ligament into a lateral compartment (psoas major, iliacus and femoral nerve) and medial compartment (femoral artery laterally and femoral vein medially).

    The lateral compartment contains the fascia iliaca compartment (lacuna musculorum). The floor of this compartment is formed by the iliacus and psoas major, the roof by the fascia iliacus. Sandwiched between the floor and the roof is a potential space containing the femoral nerve.

    The medial compartment contains the femoral sheath. The posterior wall of the femoral sheath is formed from the iliacus fascia (lacuna vasorum). The anterior wall of the femoral sheath is formed from the transversalis fascia, fascia lata and fascia of Scarpa (Lytle 1956). The femoral sheath contains the femoral artery and vein.

    • Pectineal ligament: the iliacus fascia passes behind the femoral vessels to become the pectineal ligament (lacunar ligament --> pectineal line of the pubic bone).
    • Muscular attachment: the iliacus fascia, in its own right and as a continuation of the transversalis fascia, gives attachment to the internal oblique and transverse abdominis muscles (Lytle, 1974). Xu et al (2018) identified the internal oblique-iliac fascia septum as a potential site of entrapment for the lateral femoral cutaneous nerve.
    • Iliopubic tract: the iliopubic tract is a thickening of the transversalis fascia. The iliacus fascia provides a lateral attachment to the iliopubic tract as it extends from the transversalis fascia to the fascia iliacus (Teoh et al 1998).
    • The iliacus fascia descends into the thigh as the fascia lata and is also continuous with the sartorius and pectineal fascia (a condensation of the transversalis fascia overlying the pectineal ligament).

    Neurological relations:

    The iliacus fascia covers the:

    • Femoral nerve.
    • Obturator nerve.
    • Lateral femoral cutaneous nerve.

    Psoas Fascia

    The Psoas fascia attachments are:

    • Superior: the psoas fascia blends with the diaphragm (medial arcuate ligament, Van Dyke et al 1987 and right and left crus, Sajko & Stuber 2009) and lumbar spine via the diaphragmatic attachments (including anterior longitudinal ligament, Sajko and Stuber 2009). Van Dyke et al (1987) found the psoas fascia continuous superiorly with the endothoracic fascia. The transversalis fascia extends around the inner surface of the transverse abdominis, quadratus lumborum and the psoas major, where it gets renamed the psoas fascia. It thus forms one continuous fascial sheet. Extending superiorly, to form the subdiaphragmatic fascia, the transversalis fascia passes through the medial and lateral arcuate ligaments and aortic hiatus to be renamed the endothoracic fascia (Elsharkawy et al 2019).
    • Inferior: the psoas fascia merges with the endopelvic fascia of the pelvic floor (this forms a link with the conjoint tendon, transverse abdominus, and the internal oblique, Sajko & Stuber 2009), pelvic brim (as the psoas major courses over the pelvic brim the fascia of the posterior fascicles attach firmly to it Sajko & Stuber 2009) and the fascia lata (Van Dyke et al 1987). Again the transversalis fascia extends over the psoas major where it gets renamed the psoas fascia making them “both” one continuous sheet of fascia. As well as blending with the iliacus fascia Raychaudhuri & Cahill (2008) found the transversalis fascia descends as the endopelvic fascia lining the walls and floor of the pelvis covering the obturator internus, piriformis, levator ani and coccygeus. 
    • Anteriorly: the psoas fascia merges with the fascia that covers the kidneys, the pancreas, the descending aorta, the inferior vena cava, the colon (ascending and descending), the duodenum and the cecum (Bordoni and Varacallo 2019)
    • Posteriorly: the psoas fascia merges with the transversalis fascia covering the quadratus lumborum.

    Contiguous structures include (Van Dyke et al 1987):

    • Vertebral bodies.
    • Intervertebral discs.
    • Posterior paraspinal muscles.
    • Innominate bone.
    • Lumbar vessels.
    • Branches of the sympathetic trunk that pass beneath the tendinous arches of the psoas major.
    • Nerves of the lumbar plexus pass through the psoas major.

    Anatomy of the inguinal ligament

    The inguinal ligament extends from the ASIS to the pubic tubercle and pectin pubis. Some fibres near the ASIS may end in the fascia lata. 

    The inferior surface of the narrow lateral half of the inguinal ligament is fixed to the fascia lata. This part of the fascia lata is an extension of the fascia iliaca. The fascia iliaca descends over the iliacus, under the inguinal ligament attaching to its underside and into the thigh as the fascia lata.

    The under surface of the medial part of the inguinal ligament, before it reaches its attachment to the pubic tubercle and pecten pubis, is fixed to the pectineus muscle and fascia (a condensation of the transversalis fascia overlying the pectineal ligament).

    The superior aspect of the inguinal ligament gives attachment to the internal oblique and transverse abdominis. Lytle (1974) found the fascia iliaca, posterior to the inguinal ligament, also gave attachment to muscle fibres of the internal oblique and transverse abdominis muscles. Xu et al (2018) found the internal oblique-iliac fascia septum as a potential site of entrapment for the lateral femoral cutaneous nerve.

    Fascia lata arises from the posterior border of the inguinal ligament.

    • Femoral sheath: the fascia lata passes down to cover and blend with the anterior wall of the femoral sheath. Here it blends with Scarpa’s fascia and the transversalis fascia as it descends from the anterior abdominal wall over the inguinal ligament (Lytle 1956). The posterior wall of the femoral sheath is formed from the fascia iliaca.
    • Lacunar ligament: medial to the femoral sheath the fascia lata attaches to the posterior border of the inguinal ligament to form the lacunar ligament.

    The myofascial attachments of the inguinal ligament are:

    • Cremaster muscle (Lunn 1948).
    • Deep fascia of pectineus (Lunn 1948)
    • External oblique aponeurosis: forms the medial half of the inguinal ligament (Lunn 1948).
    • Fascia iliaca: a thickened strip of the fascia iliaca forms the superolateral part of the iliopectineal arch (Acland 2008).
    • Fascia lata (Lytle 1974).
    • Transversalis fascia.
    • The iliopubic tract or deep femoral arch (Lytle 1974).

    Mechanical movement of the inguinal ligament

    Lunn (1948) found the medial half of the inguinal ligament is more mobile than the lateral. (No author, 1835) found when the thigh is extended and rotated outwards this produced a stretch on the crural arch (inguinal ligament) drawing it downwards without producing much effect upon the lacunar ligament. This was produced by stretching the part of the fascia lata attaching on to [and forming] part of the lacunar ligament and anterior part of the femoral canal. The author found flexing and rotating the thigh inwards had the opposite effect.

    Anatomy of the lacunar ligament

    The lacunar ligament is attached in front to the posterior border of the inguinal ligament and behind the pecten pubis being fused, along with the inguinal ligament, to the pectineus muscle and its fascia (a condensation of the transversalis fascia overlying the pectineal ligament).

    The lacunar ligament, with the pectineus muscle and its fascia, passes upwards and backwards to reach the pectineal ligament on the pecten pubis

    The lacunar ligament is derived from the fascia lata of the thigh. It is reinforced by the transversalis fascia. It gives rise to the anterior part of the femoral canal and supports the femoral vein.

    The fascia lata attaches to the lacunar ligament and continues down to blend with the medial aspect of the femoral sheath. As it descends in the thigh it is known as the cribiform fascia.

    Function of the inguinal and lacunar ligaments

    The inguinal and lacunar ligaments:

    • Forms a strong protective diaphragm between the abdomen and the thigh.
    • Forms a broad aponeurotic floor for the inguinal canal which keeps its anterior and posterior walls apart to give roomy passage for the spermatic cord.
    • Supports the femoral sheath and holds open the lumen of the large thin-walled femoral vein, fixed within the walls of the femoral sheath, amid the stresses and strains of thigh movement and variations of intra-abdominal pressure and body posture.

    References

    THE COMPARATIVE ANATOMY OF THE INGUINAL LIGAMENT (1948) By H. F. LUNN

    The inguinal ligament and its lateral attachments: Correcting an anatomical error† (2008). Robert D. Acland

    The inguinal and lacunar ligaments W. J. LYTLE (1974)

     STUDY OF ANATOMICAL PATTERN OF LUMBAR PLEXUS IN HUMAN (CADAVERIC STUDY) BY Prof. Gamal S Desouki, prof. Maged S Alansary,dr Ahmed K Elbana and Mohammad H Mandor 

    Review of iliopsoas anatomy and pathology (1987). Jerrold A. Van Dyke, Howard C. Holley, Susan D. Anderson.

    The iliopubic tract: an important anatomical landmark in surgery (1998)  LAURENCE S. G. TEOH , GUY HINGSTON , SAAD AL-ALI, BRENDA DAWSON AND JOHN A. WINDSOR

    THE COMPARATIVE ANATOMY OF THE INGUINAL LIGAMENT (1948) By H. F. LUNN

    Inguinal anatomy. (1979). W J Lytle

    Anatomical Description of the Parts Concerned in Inguinal and Femoral Hernia (1835). No author 

    Review of iliopsoas anatomy and pathology (1987)

    Jerrold A. Van Dyke, M.D. Howard C. Holley, Susan D. Anderson.

    Psoas Major: a case report and review of its anatomy, biomechanics, and clinical implications (2009). Sandy Sajko and Kent Stuber.

    Anatomy, Bony Pelvis and Lower Limb, Iliopsoas Muscle (2019). Bruno Bordoni; Matthew Varacallo

    Fascia Iliaca Compartment Block: LANDMARK AND ULTRASOUND APPROACH ANAESTHESIA TUTORIAL OF THE WEEK 193 23rd AUGUST 2010 Dr Christine Range and Dr Christian Egeler.

    FEMORAL HERNIA Lecture delivered at the Royal College of Surgeons of England on 12th October 1956 by W. J. Lytle.

    Fine architecture of the fascial planes around the lateral femoral cutaneous nerve at its pelvic exit: an epoxy sheet plastination and confocal microscopy study (2018). Xu Z, Tu L, Zheng Y, Ma X, Zhang H, Zhang M. 

    The deep layer of the tractus iliotibialis and its relevance when using the direct anterior approach in total hip arthroplasty: a cadaver study (2017). David Putzer, Matthias Haselbacher, Romed Hörmann, Günter Klima, and Michael Nogler

    Extensile Exposure. 2nd ed. (1957). Henry AK. pp. 209–210.

    Quadratus Lumborum Block Anatomical Concepts, Mechanisms, and Techniques (2019) Hesham Elsharkawy, Kariem El-Boghdadly, Michael Barrington.

    Anatomical Description of the Parts Concerned in Inguinal and Femoral Hernia (1835). No author

    Pelvic fasciae in urology (2008). Raychaudri B, Cahill, D

    THE PELVIC FLOOR—CONSIDERATIONS REGARDING ITS ANATOMY AND MECHANICS (1927). A. W. Meyer

    A practical treatise on abdominal hernia (1846). Thomas Pridgen Teale

    Anatomical description of the parts concerned in inguinal and femoral hernia, translated from M. Jules Cloquet; with lithographic plates from the original etchings and a few additional explanatory notes (1835). Andrew Melville